Department of Pathology
and Laboratory Medicine

Akron Children's Hospital
One Perkins Square
Akron, OH 44308
Laboratory
Ph: (330) 543-8573
Fax: (330) 543-3659

LABORATORY TEST REQUISITION


PATIENT INFO
Patient Name:
Medical Record #:
BD:        /        /              Sex:    F    M

PHYSICIAN INFO
Physician Name :
Address:
Ph: (        )        -              Fax: (        )        -              
Additional Report to:
Ph: (        )        -              Fax: (        )        -              

TESTS REQUESTED
Test Name: ICD9 Code: (required)
1. Tumor Necrosis Factor   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Tumor Necrosis Factor
CPT Code: 83520

Specimen Type: Blood

Tube Type/Collection Container: Red top (no additive) tube

Collection Volume: 2.5mL (minimum 1.25mL)

Storage: Frozen

Availability: Sent to reference lab, Days performed: Tues

Methodology: Enzyme Linked Immunosorbent Immunoassay

Special Instructions: Allow blood to clot 10-15 minutes, centrifuge, and separate serum from cells. Freeze ASAP. Cytokine levels may demonstrate diurnal variation. Recommend cytokine levels be determined at the same time of day for improved longitudinal comparison.

TAT: 4-12 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: 1.2-15.3 pg/mL

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Cindy Maurer at (330)543-8689.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: